What is the protocol when a teenager suffers a head injury?

Head Injury Protocol for Teenagers

When a teenager hits their head, immediately remove them from activity and assess for high-risk features requiring emergency CT imaging: altered mental status, loss of consciousness, severe mechanism of injury, signs of skull fracture, persistent vomiting, severe headache, or focal neurological deficits. 1

Immediate Assessment and Risk Stratification

Remove from play immediately - never allow return to activity the same day, even if symptoms resolve. 1, 2

Red Flags Requiring Emergency Evaluation:

• Loss of consciousness (any duration) 1
• Altered mental status or confusion 1
• Repeated vomiting 1
• Severe or worsening headache 1
• Seizure activity 1
• Focal neurological deficits 1
• Signs of basilar skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF leak) 1
• Glasgow Coma Scale score <15 1

CT Imaging Indications:

Obtain non-contrast head CT if any of the following are present: 1

• GCS score <15 at any point 1
• Loss of consciousness or post-traumatic amnesia 1
• Vomiting 1
• Severe headache 1
• Dangerous mechanism (motor vehicle collision, fall >3 feet/5 stairs, high-impact sports collision) 1
• Any coagulopathy or anticoagulant use 1

Acute Management (First 24-48 Hours)

Implement complete physical and cognitive rest for the first 24-48 hours after injury. 3, 4, 2

Physical Rest:

• No sports, exercise, or strenuous physical activity 3, 2
• Avoid activities that increase heart rate significantly 3
• No contact or collision activities 3, 2

Cognitive Rest:

• Limit screen time (phones, computers, video games, television) 3, 2
• Reduce academic workload 3, 2
• Avoid activities requiring intense concentration 3

Medication Guidelines:

• Avoid NSAIDs (ibuprofen, naproxen) and aspirin in the first 24-48 hours due to theoretical bleeding risk 4
• Acetaminophen may be used cautiously for headache if needed 4, 2
• Do not mask symptoms with medication to return to activity 2

Gradual Return to Activity (After 48 Hours)

Critical: Avoid strict prolonged rest beyond 3 days, as this can worsen outcomes and delay recovery. 3, 2

Progressive Return Protocol:

Each step requires minimum 24 hours and must be symptom-free before advancing: 2

1. Light aerobic exercise (walking, stationary cycling) - stays below symptom threshold 3, 2
2. Sport-specific exercise (running drills, skating) - no contact 2
3. Non-contact training drills (passing, resistance training) 2
4. Full-contact practice (requires medical clearance) 2
5. Return to competition 2

If symptoms recur at any step, return to the previous level and rest 24 hours before attempting to progress again. 2

Supervised Exercise Benefits:

• Introduce supervised, non-contact aerobic exercise below symptom-exacerbation threshold 3
• Exercise is particularly beneficial for adolescents with acute concussion (strong evidence) 3
• Monitor symptom number and severity closely during progression 3, 2

Return to School/Academics

Gradually increase academic activities as tolerated, with accommodations as needed: 3, 2

• Shortened school days initially 2
• Extended time for assignments and tests 2
• Reduced workload 2
• Breaks during the day as needed 3
• Customize based on symptom severity 3

Monitoring for Complications

Instruct the teenager and family to return immediately if any of these develop: 1

• Repeated vomiting 1
• Worsening headache 1
• Increased confusion or memory problems 1
• Abnormal behavior 1
• Increased sleepiness or difficulty waking 1
• Seizures 1
• Focal neurological deficits 1

Recovery Timeline and Expectations

Most teenagers recover within 7-10 days, though some may take weeks to months. 1, 2

Post-Concussive Symptoms (if lasting >3 weeks):

• Chronic headaches 1
• Dizziness, balance problems 1
• Vision problems 1
• Sensitivity to noise/light 1
• Memory and concentration difficulties 1
• Sleep disturbances 1
• Mood changes, irritability, anxiety 1

Refer to a specialist in traumatic brain injury if symptoms persist beyond 3 weeks or if considering return to sports. 1

Return to Full Activity Criteria

Allow return to full activity only when the teenager: 3, 2

• Has returned to premorbid performance level 3
• Remains completely symptom-free at rest 3, 2
• Shows no symptom recurrence with increasing physical exertion 3
• Has received medical clearance from a physician experienced in concussion management 1

Critical Pitfalls to Avoid

• Never allow same-day return to play, even if asymptomatic 1, 2
• Do not exceed 3 days of strict rest - this can worsen outcomes 3, 2
• Avoid high-intensity physical activity during recovery - this is detrimental 3
• Do not return to contact sports while taking any concussion medications 2
• Home observation with frequent waking is NOT recommended for patients with negative CT or low-risk features 1

Special Considerations for Multiple Concussions

Consider prolonged removal from sports or permanent retirement if: 1

• Three or more concussions in a single season 1
• Post-concussive symptoms lasting >3 months 1
• Referral to a specialist is mandatory for these decisions 1